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Insurance - GCI Construction - 2014-06-16
AC®RL CERTIFICATE OF LIABILITY INSURANCE DATE(MW L...../ 6/16/2014 THIS CERTIFICATE IS ISSUED AS'A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES• BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Com p ass CONTACT Direct Insurance Services, Inc. NAME: Jeremy Seltzer 13681 Newport Ave., Ste 8#622 PHONE FAX Tustin, CA 92780 (A/c.No.Ext): 714-665-9800 (A/C,No): 714-665-9801 E-MAIL ADDRESS: leremy@4 cdisi.com INSURER(S)AFFORDING COVERAGE NAIC# www.cdisi.com License#0H16100 INSURER A: Great American Assurance Company 26344 INSURED INSURER B: Wesco Insurance Company 25011 GCI Construction, Inc. . 1031 Calle Recodo, Ste. D INSURER C: Security National Insurance Company 19879 San Clemente CA 92673 INSURERD: American Zurich Insurance Company 40142 • INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 20532167 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSD sWVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A COMMERCIAL GENERAL LIABILITY / / GLP1862447 4/1/2014 4/1/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE / OCCUR PREMISES O(Ea occurrence) $ 50,000 ✓ Owner's/Cont. Pro MED EXP(Any one person) $ Excluded ,/ XCU/Deductible$5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ✓ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Employee Benifits $ 1,000,000 B AUTOMOBILE LIABILITY ✓ ✓ WPP1055077 02 4/1/2014 4/1/2015 ((EOMaBIINdEeDtSINGLE LIMIT $ 1'000'000 / ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ✓ HIRED AUTOS ✓ AUTOS NON-OWNED Comp/Coll Ded$1,000 Perry cid ntDAMAGE $) No Liability Deductible - $ A �/ UMBRELLA LIAB / OCCUR / / UMB 1862448 4/1/2014 4/1/2015 EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED RETENTION$ - _ $ C WORKERS COMPENSATION ✓ SWC1042490 3/17/2014 3/17/2015 ✓ STATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B IM-Eqp./Lesd-Hrd-R WPP1055077 02 4/1/2014 4/1/2015 Sch/Per:641K/150K D Builders Risk ER06680120 6/2/2014 6/2/2015 Limit: 108,650 DESCRIPTION OF OPERATIONS/LOCATIONS./VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:GCI Job No.424 Certificate holder and its employees,agents and officials are named as additional insured as per attached endorsements with respects to work performed by the insured as per contract. *10 day notice for non-payment of premium* CERTIFICATE HOLDER CANCELLATION ' GCI Job No.424 Costa Mesa Sanity District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sanitary THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 628 E. 19th Street ( �� i ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa CA 92627 c�(1yf/\ U V AUTHORIZED REPRESENTATIVE I Jeremy Seltzer ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 1 of 8 Great American Assurance Company GLP1862447 CG 20 33 GCI Construction, Inc. (Ed. 07 04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II - WHO IS AN INSURED is This insurance does not apply to: amended to include as an Additional Insured any person or organization for whom you are 1. "Bodily injury," "property damage" or "per- performing operations when you and such sonal and advertising injury" arising out of person or organization have agreed in writing the rendering of, or the failure to render, in a contract or agreement that such person any professional architectural, engineering or organization be added as an Additional In- or surveying services, including: sured on your policy. Such person or or- ganization is an Additional Insured only with a. the preparing, approving, or failing to respect to liability for "bodily injury," "prop- prepare or approve, maps, shop erty damage" or "personal and advertising in- drawings, opinions, reports, surveys, jury" caused, in whole or in part, by: field orders, change orders or draw ings and specifications; or b. supervisory, inspection, architectural 1. your acts or omissions; or or engineering activities. 2. "Bodily injury," or "property damage" oc- 2. the acts or omissions of those acting on curring after: your behalf; a. all work, including materials, parts or equipment furnished in connection in the performance of your ongoing oper with such work, on the project (other ations for the Additional Insured. than service, maintenance or repairs) to be performed by or on behalf of the Additional Insured(s) at the location of the covered operations has been A person's or organization's status as an Ad completed; or ditional Insured under this endorsement ends when your operations for that Additional In- b. that portion of "your work" out of sured are completed. which the injury or damage arises has been put to its intended use by any person or organization other than an- B. With respect to the insurance afforded to other contractor or subcontractor en- these Additional Insureds, the following addi- gaged in performing operations for a tional exclusions apply: principal as a part of the same project. Copyright, ISO Properties, Inc., 2004 CG 20 33 (Ed. 07/041 XS CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 2 of 8 Great American Assurance Company GLP1862447 GAC 3649CG GC] Construction, Inc. (Ed. 11 061 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory. GAC 3649CG (Ed. 11/06) XS CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 3 of 8 Great American Assurance Company GLP1862447 CG 25 03 GC' Construction, Inc. (Ed. 03 97) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECTS) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: Any construction project where "you" are performing operations when "you" have agreed in writing in a contract or agreement that a separate General Agg-regate Limit shalI apply to such construction project , but only if "your work " on or at the construction project is performed during the period of this policy , (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION I), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project .General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A. except damages because of "bodily injury" or "property damage" included in the "products—completed operations hazard," and for medical expenses under Coverage C. regardless of the number of: a. Insureds; b. claims made or "suits" brought; or c. persons or organizations making claims or bringing "suits." Copyright, Insurance Services Office, Inc., 1996 CG 25 03 (Ed. 03/97) PRO (Page 1 of 2) CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (POT) Page 4 of 8 3. Any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION I), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products—Completed Operations Aggregate Limit, whichever is applicable; and 2. such payments shall not reduce any Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products—completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products—completed operations hazard" will reduce the Products—Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of LIMITS OF INSURANCE (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright, Insurance Services Office, Inc., 1996 CG 25 03 (Ed. 03/97) PRO (Page 2 of 2) CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 5 of 8 WPP1055077 02 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM • GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. • Endorsement Effective: 4/1/2014 Countersigned By: 41. / Named Insured: GCI Construction, Inc. (Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): Blanket as required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 6 of 8 WPP1055077 02 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: GCI Construction, Inc. Endorsement Effective Date: 4/1/2014 SCHEDULE Name(s) Of Person(s) Or Organization(s): Blanket as required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 ❑ CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 7 of 8 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.00% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization as required by written contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 3/17/2014 Policy No.SWC1042490 Endorsement No. WC 04 03 06 Insured GCI Construction, Inc. Premium$ Insurance Company Security National Insurance Company CERT NO.: 20532167 Laura Yardeen 6/16/2014 3:06:44 PM (PDT) Page 8 of 8